ORDER

GULSHAN PRASHAR (MEMBER)

1. Brief facts of the present complaint are that complainant become the member of Bhai Ghaniya Sehat Sewa Scheme Policy and he was issued membership card No.9011037 89000012 by respondent No. 2 on payment of Rs.1832/- Unfortunately, the

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complainant was hospitalized and prior to his admission, he checked the cashless facility being available at Joshi Hospital, Jalandhar. All the documents were sent to the respondent No. 2 through Joshi Hospital. But the complainant was asked to pay Rs.1,30,000/- a treatment amount because firstly Angiography was done, followed by bye-pass surgery as he was having no time left except go for it to save his life.

2. That since the complainant had paid the amount to the opposite parties under the said scheme, hence they are bound to pay the treatment amount of complainant at Joshi Hospital and refusal to pay the same, is deficiency in service on their part. Hence the present complaint. The complainant also served a legal notice dated 17.8.2009 but to no effect. Hence the present complaint.

3. On notice, the opposite parties appeared and filed written statement by taking the plea that the complainant has concealed the true facts and is estopped by his own act and conduct from filing the present complaint. The bye-pass surgery was a complication of pre-existing disease which is a violation of the terms and conditions of the policy as such, the complaint is liable to be dismissed. All other allegations made in the complaint have been emphatically denied and it is prayed that the complaint is liable to be dismissed.

4.. The counsel for the complainant has tendered into evidence affidavit of complainant Ex.CA along with documents Ex.C1 to Ex.C27 and closed the evidence.

5. On the other hand the opposite party No.2 has tendered into evidence affidavits Ex.OP2/A and Ex.OP2/B along with documents Ex.OP2/B1 to Ex.OP2/B13 and closed the evidence.

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6. The counsel for the complainant has drawn our attention to a booklet Ex.C7 which contains guidelines and the list of hospitals which are authorized by Bhai Ghaniya Sehat Sewa Scheme Network for the treatment of different diseases covered under this scheme. At page No. 6 of this booklet, Serial No. 1.9 is mentioned. In Serial No. 1.9, there is a table of different diseases and the different amounts are also mentioned which can be spent for curing the particular disease. At Serial No. 5, there is mentioned of operation of heart and against this operation of the heart, Rs.1,50,000/- is mentioned and if the expenditure is more than Rs.2,00,000/-, than the concerned member will bear the total amount over Rs.2,00,000/-. Ex.C26 is the list of the beneficiary from this scheme known as Bhai Ghaniya Sehat Sewa Scheme Policy and the name of the present complainant Paramjit Singh son of Sohan Singh, r/o. Village Kanjli Tehsil and District Kapurthala is mentioned at Serial No. 24. Ex.C25 is the ration card of Paramjit Singh and there is a photograph of Paramjit Singh and the members of his family. Paramjit Singh complainant was hospitalized on 14.8.2009 in Joshi Hospital, Jalandhar and prior to his admission, he checked if the cashless facility is available at Joshi Hospital or not. All the documents were sent through opposite party No. 2 to Joshi Hospital. The complainant was in need of emergency treatment and he was asked to pay Rs.1,30,000/-as treatment amount because firstly Angiography was done, followed by bye-pass surgery as he was having no time left except to go for it to save his life. Surgery was successful at Sh Ram Cardiac Centre Joshi Hospital premises, Kapurthala Road Jalandhar the complainant

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Paramjit Singh son of Sohan Singh, was admitted on 14.8.2009 and was discharged after surgery on 29.8.2009, where Rs.10,000/- was charged for Coronary Angiography and Rs.1,20,000/- was the bill of the hospital for Coronary Angiography and surgery. The total medical bill for the surgery was Rs.1,30,000/-. This was attested by the cashier of Shri Ram Cardiac Centre Joshi Hospital and the same is Ex.C6. The opposite parties denied the payment of cashless facility the the complainant vide letter dated 17.8.2009 without any reason. The refusal by the opposite parties to provide cashless facility to the complainant is illegal, malpractice, deficiency in service on their part. the respondents inquired about the diseases from the complainant at the time of issuing of the membership card and receipt of the payment of policy. So this is a clear cut case of deficiency in service and unfair trade practice by the opposite party. After the perusal of the above saids original documents, we are of the view that Paramjit Singh son of Sohan Singh, was the member of Bhai Ghaniya Sehat Sewa Scheme Policy and by this membership he had paid Rs.1832/- as membership fee and his name is shown in the list of members at Sr. No.24.

So we accept the complaint and direct the opposite parties to pay a sum of Rs.1,30,000/- (Rupees One Lac Thirty Thousand) to Paramjit Singh son of Sohan Singh for his treatment of Coronary Artery Bye-pass Surgery along with interest @ 8% P.A. from the date of repudiation of claim i.e. 17.8.2009 till the date of realization, besides Rs.5000/- as costs of the complaint payable by the opposite

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party to the complainant within one month from the receipt of the copy of the order. Copy of the order be sent to the parties through registered post free of costs. File be consigned to the record room.

Dated: Shashi Narang Gulshan Prashar Paramjit Singh

5-3-2010 Member Member President